The Journal of the American Academy of Dermatology has issued an expression of concern about a 2012 article reporting the experience of military burn unit treating a rare ailment called toxic epidermal necrolysis.

According to the notice, which is behind a paywall (for shame!), the paper appears to have overstated the number of cases the hospital itself has treated of the life-threatening condition:

The Journal of the American Academy of Dermatology has been notified of possible data irregularities in a previously published article: Firoz BF, Henning JS, Zarzabal LA, Pollock BH. Toxic epidermal necrolysis: Five years of treatment experience from a burn unit. J Am Acad Dermatol 2012;67:630-5.

As stated by the authors, this article details their experience treating 82 patients with a potentially fatal condition, toxic epidermal necrolysis (TEN), over a 5 year period at the burn unit of the Brooke Army Medical Center (BAMC) in San Antonio. All are said to have had a confirmatory biopsy. The complaint alleges 2 major discrepancies in the report:

(1) The burn unit database indicates that no more than 48 patients with TEN were admitted there in any 5 year period in the last 9 years.

(2) Only 75% of these had the diagnosis confirmed by biopsy.

The Editor of the Journal of the American Academy of Dermatology and his staff have gone to great lengths to investigate this issue. The lead author has argued that the BAMC burn unit database is incorrect with regard to the number of TEN patients treated. She has stated that the published number of 82 is accurate because (a) some of the patients were incorrectly diagnosed initially by burn unit physicians and later found to have TEN, (b) they included in their report patients with TEN/Stevens-Johnson syndrome overlap (this was not specifically stated in the manuscript), and (c) some of the patients were treated using an “almost identical” protocol at Wilford Hall Medical Center (WHMC), an Air Force facility, rather than at BAMC; again, this was not specifically stated in the manuscript, which indicated that all patients were treated at the BAMC burn unit.

The possible inaccuracies described above have prompted our “expression of concern” regarding this report.

The paper has been cited eight times, according to Thomson Scientific’s Web of Knowledge.

Although we sometimes think expressions of concern are like the gentleman’s C of retractions, on the surface, the journal’s approach here seems to make sense. It seems as if the authors — or, at least, the first author — may have used shorthand to avoid nuance. In the absence of a clear indication of misconduct, retraction here doesn’t seem to be the right move.

And yet…

The problem is that the paper has already been the subject of a correction that would have been a retraction in many other journals:

The Chairman of the Institutional Review Board at the medical center where data for the above-referenced article was generated has informed JAAD staff that contrary to the statement on page 631, this study was never submitted for institutional review board (IRB) approval. We remind our authors and readers that, as per the JAAD Information for Authors, IRB approval is required for all studies involving live human or animal subjects.

We’ve contacted the first author for more details, and will update with anything we learn.

Maybe — but remember that serious questions have been raised about the validity of an awful lot of important papers. Three classic examples:

1. Concerns about the priority of Einstein’s special relativity paper
2. Concerns about data over-interpretation or fudging in Eddington’s paper confirming Einstein’s analysis of the precession of Mercury
3. Concerns about discovery credit for Rosalind Russel’s work in the Watson & Crick DNA structure.

The consensus is that none of these concerns are ultimately valid; but none of the criticisms were trivial, either. Knowledgeable people have vigorously argued all of them, even in the last few years.

The standards of proof for retraction ought to be kept fairly high, although perhaps not as high as they were twenty years ago.